Healthcare Provider Details

I. General information

NPI: 1972864460
Provider Name (Legal Business Name): PREMIER MED SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2012
Last Update Date: 05/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11207 S LA CIENEGA BLVD STE 102
LOS ANGELES CA
90045-6112
US

IV. Provider business mailing address

11207 S LA CIENEGA BLVD SUITE 102
LOS ANGELES CA
90045-6112
US

V. Phone/Fax

Practice location:
  • Phone: 855-258-6352
  • Fax: 855-258-6353
Mailing address:
  • Phone: 855-258-6352
  • Fax: 855-258-6353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY50857
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DEYDA CUELLAR
Title or Position: OFFICE MANAGER
Credential:
Phone: 855-258-6352